Employment

Name

First

Last

Address (Street Address, Town/City, State)

Phone Number

Email

Certification Level

MA EMT/Paramedic Certification Number

NREMT Number

Do you have a valid driver's license & reliable transportation?

Please list any additional EMS certifications (TECC, PHTLS, AMLS, etc). Please include certification numbers and expiration dates.

How many hours are you looking for?

Shift Availability

Hours/shifts will be discussed during initial interview.

Do you have prior EMS experience? If so, how many years?

I attendance, Please

Please describe past work experience (3 most recent preferred). Include contact information for previous/current employers if we may contact them.

Were you referred to us? If so, please specify here.

Have you been employed by the West Brookfield Rescue Squad in the past? If so, when?

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize West Brookfield Rescue Squad, Inc. to contact former employers regarding my employment. I authorize my former employers to fully and freely communicate information regarding my previous employment, attendance, and professionalism. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment.

Agree

Electronic Signature & Date

West Brookfield Rescue Squad

Employment Application